Cannabidiol for the prevention and treatment of graft-versus-host disease

ABSTRACT

The invention provides methods for preventing, ameliorating and treating the acute and chronic forms of graft-versus-host disease (GVHD) by using Cannabidiol compositions.

FIELD OF THE INVENTION

The present invention relates to methods and uses of Cannabidiolcompositions in the prevention and treatment of the acute and chronicforms of graft-versus-host disease (GVHD).

BACKGROUND OF THE INVENTION

Graft-versus-host disease (GVHD) is a most frequent complication ofallogeneic hematopoietic stem cell transplantation (HSCT) and isassociated with significant morbidity and mortality. Mortality rates asa direct or indirect consequence of GVHD can reach 50% despite theprophylactic use of immunsuppressive drugs like cyclosporine,tacrolimus, ATG, methotrexate, and mycophenolate mofetil which areadministered for prevention of GVHD. Two distinct types of GVHD areclinically recognized, acute and chronic. The acute form of the diseaseusually develops within the first three months after transplantation.The skin, liver and gastrointestinal tracts are the main targets ofacute GVHD. Newly transplanted, donor lymphocytes react to the hosttissue antigens, resulting in cell damage to a variety of organs. Theincidence rate of acute GVHD is estimated at 30-50% among patientsreceiving transplant from HLA-identical sibling donors, and 50-70% in.patients receiving MA-matched unrelated transplants. Severe acute GVHD(grade III-IV) occurs in up to 20% of recipients of related donors(Champlin, Blood 2000; 95:3702-3709) and up to 35% of unrelated donors(Castro-Malaspina, Blood 2002; 99:1943-1951, McGlave, Blood 2000;95:2219-2225, Jagasia, Blood 2012; 119:296-307). Non-relapse mortalityin patients who develop acute GVHD has been estimated to be in the rangeof 28% to 92%. Long term survival after grade I acute GVHD is greaterthan 90%, contrasting with 80%, 30%, and 10% for grades II, III, and IV,respectively.

Chronic GVHD occurs in up to 60% of patients receiving HLA-identicalsibling marrow grafts and 70% of patients receiving alternative donormarrow grafts who survive beyond day 100. (Lee, BBMT 2003; 9: 215-233).Symptoms of chronic GVHD usually present between 3 months and 2 yearsafter allogeneic transplantation, about two thirds develop within thefirst 12 months. Manifestations of chronic GVHD may be restricted. tosingle organ or tissue, but typically 2 or 3 organs are involved. Theorgans most commonly affected are the skin, mouth, and eyes, with morethan 50% of patients demonstrating these manifestations. Other diseasesites include the liver, lungs, gastrointestinal tract, musculoskeletalsystem, and female genital organs.

Chronic GVHD can lead to debilitating consequences such as jointcontractures, loss of sight, end-stage lung disease, and mortality frominfection. The 3 year risk of non-relapse mortality in patients withchronic

GVHD ranges from 28% to 48% depending on the extent of GVHD. Mortalityrates are increased in patients with extensive disease (more thanlimited skin or liver involvement), progressive onset (chronic GVHDevolving directly from acute GVHD), thrombocytopenia, andHLA-non-identical donors. The overall survival rate is 42%, but patientswith progressive onset of chronic GVHD have a survival rate of 10%.

Altogether, only less than 20% of transplanted patients do not developeither acute or chronic GVHD (Flowers, Blood 2011; 117(11); 3214-3219).

It is well accepted that acute and chronic GVHD are unique differentprocesses. This fact is emphasized by the observations that chronic GVHDcan occur without prior acute GVHD, and that interventions that aresuccessful in preventing or treating acute GVHD most commonly fail. todecrease chronic GVHD (Pavletic, Blood 2005; 106:3308-3313, Thomashematopietic cell transplantation, 4^(th) edition, page 1307,Wiley-Blackwell). Most investigators now consider chronic GVHD as adisease of immune dysregulation that involves donor-derived immune cellsand host cell populations and tissues. This process is likely initiatedby donor-derived T cells and is both alloreactive (directed against therecipient's histocompatibility antigens) and autoreactive (directedagainst antigens present on both the donor and recipient). The activatedimmune response then proceeds unchecked by the thymic or peripheralmechanisms of deletion and immunoregulation. Critical donor or recipienttolerance-promoting mechanisms may be absent.

Conventional treatment of chronic GVHD requires prolonged periods ofsystemic immunosuppressive therapy with potent drugs such ascorticosteroids and cyclosporine. Agents such as mycophenolate mofetil,rapamycin (sirolimus), imatinib and rituximab are used in patients withsteroid-refractory chronic GVHD. However, these treatments have limitedeffectiveness, and cause very often severe adverse effects. Only 50% ofpatients with chronic GVHD are able to discontinue immunosuppressivetreatment within 5 years after diagnosis, and 10% require continuedtreatment beyond 5 years. The remaining 40% die or develop recurrentmalignancy before chronic GVHD resolves. 5 year survival rates ofpatients with high risk chronic GVHD (platelet counts<100,000/microliter or progressive onset from aGVHD) is only 40-50%.

Thus, developing innovative strategies to prevent and treat GVHD is amajor unmet need.

The cannabis plant (Cannabis saliva) has been in use for medicalpurposes for thousands of years. Medical Cannabis is nowadays prescribedfor prevention of nausea and vomiting associated with cancerchemotherapy, and for the treatment of anorexia associated with AIDS andcancer.

Cannabis plants produce a group of natural chemicals calledCannabinoids, among them Δ⁹-tetrahydrocannabinol (THC), Cannabidiol andajulemic acid. Cannabidiol (CBD) was first isolated by Adams [J. Amer.Chem. Soc., 6: 2194 (1940)] and its structure was elucidated byMechoulam and Shvo in 1963 (Tetrahedron 19: 2073). The synthesis ofcannabidiol in its racemic form and its natural form were reported in J.Amer. Chem. Soc. 87:3273-3275 (1965), and in Helv. China. Acta.50:719-723 (1967). Cannabidiol is the most abundant cannabinoid,contributing up to 40% of Cannabis extracts, having no psychotropiceffects, as opposed to THC.

The immune-modulatory and anti-inflammatory properties of Cannabidiolhave been shown in animal models of various inflammatory diseasesincluding multiple sclerosis (Kozela, BJP, 2011), diabetes mellitus(Weiss, Autoimmunity 2006), inflammatory bowel disease (Borrelli, J MolMed 2009) and rheumatoid arthritis (Malfait, PNAS 2000), CBD mediatesits anti-inflammatory effects by suppressing T cell proliferation, byshifting the balance from TH1 to Th2 cytokines, inhibiting thepro-inflammatory cytokine release including INFγ, TNFα, IL-1β, IL-6,IL-17 and stimulating the anti-inflammatory cytokine release includingIL-4, IL-5, IL-10, IL-13 (Mechoulam, Chem Biodivers 2007, Carrier PNAS2006, McHugh, Mol Pharmacol 2007, Lee, Int Immunopharmacol 2008, Weis,Autoimmunity 2006, Borrelli, J Mol Med 2009, Kozela, J NeuroimmunePharmacol 2013, Kozela BJP 2011, Malfait, PNAS 2000).

Unlike Δ9-tetrahydrocannabinol (THC), cannabidiol binds very weakly toCB1 and CB2 receptors [Mechoulam, R. & Hanus, L. Cannabidiol: anoverview of some chemical and pharmacological aspects. Part I: chemicalaspects. Chem Phys Lipids 121:35-43 (2002)].

CBD does not induce psychoactive or cognitive effects and is welltolerated by humans without significant adverse effects [Varga, K.,Lake, K., Martin, B. R. & Kunos, G.

CBD has also been shown to be superior to THC, in inhibitingpro-inflammatory IL-I, TNFα and IFNγ release by peripheral bloodmononuclear cells. [Watzl, B., Scuderi, P. and Watson, R. R. Influenceof marijuana components (THC and CBD) on human mononuclear cell cytokinesecretion in vitro. Adv Exp Med Biol 288:63-70 (1991);]

U.S. Pat. No. 6,410,588 describes the use of cannabidiol for treatinginflammatory diseases such as rheumatoid arthritis, multiple sclerosisand Crohn's Disease, and medicinal preparations containing CBD for usein treating such diseases.

PCT/IL01/00537 describes pharmaceutical compositions comprisingcannabidiol derivatives which have analgesic, antianxiety,anticonvulsive, neuroprotective, antipsychotic and anticancer activity.

Although the prior art teaches several potential therapeutic effects anduses of CBD it does not describe or suggest use of CBD or derivativesthereof in treating GVHD.

Therefore, it is an object of the invention to provide Cannabidiolcompositions for use in the prevention and treatment of GVHD.

A further object of the invention is the provision of a method oftreating and preventing the onset of GVHD by administering a Cannabidiolcomposition to a patient undergoing transplantation.

A still further object of the invention is the provision of the use ofCannabidiol compositions in the preparation of medicaments for theprevention or treatment of GVHD.

Further purposes and advantages of this invention will appear as thedescription proceeds.

SUMMARY OF THE INVENTION

According to one aspect the present invention there is provided a methodof preventing, ameliorating or treating graft-versus-host disease (GVHD)in a subject in need thereof. The method comprises the step ofadministering to the subject a therapeutically effective amount ofCannabidiol or any derivative thereof In some embodiments, the subjectis a patient undergoing transplantation. According to a specificembodiment, the subject is a patient undergoing allogeneic hematopoieticstem cell transplantation.

In some specific embodiments, the allogeneic hematopoietic stem cellstransplanted in the subject are received from a sibling or an unrelateddonor, from bone marrow or peripheral blood hematopoietic stem cellgrafts. Alternative sources of hematopoietic stem cells grafts are cordblood units, haploidentical peripheral blood or bone marrow stem cells.

According to some embodiments of the invention, Cannabidiol, or anyderivative thereof, is administered to a patient before and or aftertransplantation. In some specific embodiments the method may furthercomprise the step of administering of at least one additionaltherapeutic agent. In some embodiments, Cannabidiol, or any derivativethereof, is administered orally in doses of between about 5 mg to about600 mg each administration once to three times daily.

According to another aspect there is provided a pharmaceuticalcomposition for preventing or treating GVHD comprising Cannabidiol orany derivative thereof, and a pharmaceutically acceptable carrier.

According to yet another aspect there is provided Cannabidiol or anyderivative thereof, for use in the prevention and treatment of the GVHDin a subject.

DETAILED DESCRIPTION OF THE INVENTION

The inventors of the present application have surprisingly found thatadministration of a composition comprising Cannabidiol to transplanted.patients showed significant improvement in terms of reduction inincidence and severity of acute and chronic forms ofgraft-versus-host-disease (GVHD).

According to one aspect, the present invention provides pharmaceuticalcompositions for preventing and/or treating acute and/or chronic GVHD,as specified herein below, comprising Cannabidiol, or any derivativethereof. The compositions of the invention may optionally furthercomprise at least one pharmaceutically acceptable carrier, diluent,excipient and/or additive.

Two main categories of GVHD are now recognized. Acute GVHD occursusually within 100 days after transplant, while chronic GVHD occursusually beyond 100 days of transplantation.

Acute and chronic GVHD are distinct disorders, involving differentimmune cell subsets, different cytokine profiles, different hosttargets, and respond differently to treatment.

The goal of therapy of acute and chronic GVHD is to stop the destructiveimmunologic process, alleviate symptoms, and prevent disease progressionwhich may lead to irreversible disability or death. Principal componentsof GVHD therapy include systemic treatment with immunosuppressive drugsor immune modulators integrated with ancillary therapy (non-systemictreatment directed to control the symptoms such as topicalcorticosteroids, and cyclosporine eye drops) and supportive care(interventions that are directed at control of organ-specific orsystemic symptoms such as antibiotics for prevention of infections andphysical therapy). The most widely used initial systemic treatment foracute and chronic GVHD relies on prednisone alone or in conjugation withcyclosporine or tacrolimus. However, the current treatments as well assecond line available treatments are not sufficient. cause manyside-affects and are intolerable in many cases.

Cannabis sativa, also termed marijuana, is a plant known for its medicaleffects, which include easing of nausea and vomiting, anorexia, andweight loss.

The plant produces a variety of Cannabinoids, includingΔ⁹-tetrahydrocannabinol (THC) and Cannabidiol. The term “cannabinoids”refers to a heterogeneous family of molecules usually exhibitingpharmacological properties by interacting with specific receptors. Sofar, two membrane receptors for cannabinoids, both coupled to G proteinand named CB1 and CB2 have been identified. While CB1 receptors aremainly expressed in the central and peripheral nervous system, CB2receptors have been reported to be more abundantly detected in cells ofthe immune system.

THC is the main psychoactive Cannabinoid in Cannabis and is used as a.treatment for a number of medical conditions. However, its use isstrongly limited by the unavoidable psychotropic effects.

Cannabidiol constitutes up to 40% of Cannabis sativa extracts, and isrecognized as a major non-psychoactive cannabinoid, with a remarkablelack of any cognitive and psychoactive actions. CBD has potentanti-inflammatory and immunosuppressive effects. CBD has been shown toinhibit cancer cell growth and to reduce anxiety and nausea. CBD, alsotermed 2-[(6R)-3-Methyl-6-prop-1-en-2-yl-1cyclohex-2-envyl]-5pentylbenzene-1,3-diol, has the molecular formula of C₂₁H₃₀O₂.The chemical structure of CBD is shown in Formula.

Cannabidiol is insoluble in water but soluble in organic solvents, suchas oil.

The wide range of therapeutic effects can be explained by Cannabidiol'smultiple mechanisms of action. Despite its low affinity for CB1 and CB2receptors, Cannabidiol is capable of antagonizing CB1/CB2 receptoragonists. It has been reported that it can operate as a CB2 receptorinverse agonist and this may in part, contribute to its widelydocumented anti-inflammatory properties.

Other mechanisms of action include antagonism of the recently discoveredGPR55 receptor; type-1 and type 2 vanillloid receptors agonism; 5-HT1Aagonism and regulation of intracellular calcium.

The safety of Cannbidiol has been shown in several clinical studiesperformed in patient suffering from psychological or neurologicaldisorders. The reports indicate that administration of Cannbidiol indoses of up to 1500 mg per day resulted without any significant adverseeffects.

The inventors have surprisingly observed a marked alleviation insymptoms associated with both acute and chronic GVHD in transplantedpatients who smoked Cannabis in order to control pain and nausea.Interestingly, those patients also reported an increase in the severityof the GVHD symptoms when quitting smoking.

The above observations, together with the anti-inflammatory propertiesof CBD, as well as the lack of psychotropic effect and low toxicity ofthe compound, prompted the inventors to examine the therapeutic andprophylactic effects of CBD in chronic GVHD.

The present invention now demonstrates the beneficial effects oftreatment with Cannbidiol for the prevention or treatment of acute andchronic GVHD in transplanted patients. More specifically, the presentinvention demonstrates that treatment with the Cannabidiol compositionsof the invention significantly reduces the incidence of acute andchronic GVHD and its severity, as well as other complications associatedwith the disease such as infections. Accordingly, treatment with theCannabidiol compositions of the invention prevents the development ofGVHD associated symptoms and signs of the various organs and systems,including the skin, nails, mouth, eyes, female genitalia,gastrointestinal tract, liver, lungs, muscles, fascia and. joints. Thecompositions according to the present invention also appear toameliorate, or resolve acute and chronic GVHD.

Thus, in the first aspect, the invention relates to a method ofpreventing, treating, ameliorating or curing acute and chronic GVHD. Themethod of the invention comprises the step of administering to a subjectin need thereof a. therapeutically effective amount of Cannabidiol orany derivative thereof or any pharmaceutical composition comprising thesame.

It should be noted that Cannabidiol or any derivative thereof accordingto the present invention is a natural product extracted from Cannabissativa, or a synthetic product. Whenever reference is made herein to“Cannabis sativa” the same applies also to other Cannabis plantsproducing Cannabidiol, including Cannabis indica and Cannabis ruderalis,Cannabis sativa is referred to herein specifically, for the sake ofbrevity.

Cannabidiol, or any derivative thereof according to the presentinvention, can be administered to patients before or after any type ofallogeneic hematopoietic stem cell transplantation, including but notlimited to sibling and unrelated-donor bone marrow or peripheral-bloodstem cell transplantation, cord blood transplantation, andhaploidentical bone marrow or peripheral-blood stem celltransplantation.

Administration of the Cannabidiol compositions to a patient intended toundergo transplantation may start between 14 to 5 days prior to themedical procedure, more specifically 8 days before the transplant.Alternatively, treatment with the Cannabidiol compositions may beginbetween 1 to 30 days after transplantation, more specifically, 1 dayafter the transplant.

In some specific embodiments, the method of the invention may optionallyfurther comprise the step of administering at least one additionaltherapeutic agent, including currently used drugs given to transplantedpatients. These additional therapeutic agents, specifically, anyimmunomodulatory agent or known medicament, may be either combined withCannabidiol or may be administered separately in an additional separatestep having an optional different mode of administration.

In more specific embodiments, the method optionally further comprisesthe step of administering at least one additional therapeutic agentincluding but not limited to currently available medicines e.g.cyclosporine, tacrolimus, methotrexate, mycophenolate mofetil,sirolimus, ATG, imatinib or other TKIs, azathioprine, pentostatin,thalidomide, retinoids, anti-CD20, anti-CD52, ECP, corticosteroids andmesenchymal stem cells.

The pharmaceutical compositions containing Cannabidiol according to thepresent invention can be administered for prophylactic and/ortherapeutic treatments. In therapeutic application, compositions areadministered to a patient already suffering from acute or chronic GVHDin an amount sufficient to cure or at least partially arrest thecondition and its complications. An amount adequate to accomplish thisis defined as a “therapeutically effective dose.” In prophylacticapplications, compositions containing Cannabidiol are administered to apatient who is at risk of developing acute and/or chronic GVHD, i.e. apatient being before or after allogeneic transplantation. Such an amountis defined to be a “prophylactically effective dose”. Amounts effectivefor both prophylactic and. therapeutic purposes will depend upon therisk to develop GVHD, the severity of the GVHD condition and the generalstate of the patient, but generally range from about 0.01 to about 10mg/Kg body weight, specifically, about 0.5 to about 10 mg/Kg ofCannabidiol per day. Single or multiple administrations on a dailyschedule can be carried out with dose levels being selected by thetreating physician. It should be noted that doses of Cannabidiol can beelevated every day during the treatment period according to the clinicalresponse of the patient, provided no significant drug related sideeffects present.

Additionally, the administration of Cannabidiol according to theinvention, or pharmaceutical compositions comprising Cannabidiol, may beperiodic, for example, the periodic administration may be effected twicedaily, three times daily, or at least once daily for 7 days to 180 days,more preferably 90 to 180 days after transplantation for GVHD preventionand 7 days to 12 months (or longer) for the treatment of GVHD.

Specific embodiments of the invention relate to the use of typically twodoses per day, each containing at least 10 mg Cannabidiol, but usuallynot more than a daily dose of 600 mg more preferably each dosecontaining 300 mug administered twice a day.

In specific embodiments, an exemplary concentration of Cannabidiol inoil, e.g. olive oil, effective for the prevention and/or treatment ofGVHD, may range typically between about 1% weight/volume and about 3%weight/volume, more specifically, 2.5% weight/volume.

It should be noted that the Cannabidiol compositions according to thepresent invention can be prepared in any type of oil, such as canolaoil, olive oil, sunflower oil, soybean oil, corn oil, or paraffin oil.

The administration of pharmaceutical compositions comprising Cannabidiolor any derivative thereof according to the invention for the prevention,treatment, amelioration of GVHD in any form, may be any one of oral,sublingual, buccal, rectal, vaginal, parenteral, intravenous,intramuscular, subcutaneous, intra-peritoneal or via oral or nasalinhalation.

Compositions and formulations for oral administration include powders orgranules, suspensions or solutions in water or non-aqueous media,capsules, sachets, lozenges (including liquid-filled), chews, multi- andnano-particulates, gels, solid solution, liposome, films, ovules, spraysor tablets. Thickeners, flavoring agents, diluents, emulsifiers,dispersing aids or binders may be desirable.

Pharmaceutical compositions used to treat subjects in need thereofaccording to the invention, which may conveniently be presented in unitdosage form, may be prepared according to conventional techniques wellknown in the pharmaceutical industry. Such techniques include the stepof bringing into association the active ingredients with thepharmaceutical carrier(s) or excipient(s). The compositions may beformulated into any of many possible dosage forms such as, but notlimited to, tablets, capsules, liquid syrups, soft gels, suppositories,and enemas. The compositions of the present invention may also beformulated as suspensions in aqueous, non-aqueous or mixed. media. Thesuspension may also contain stabilizers. The pharmaceutical compositionsof the present invention also include, but are not limited to, emulsionsand liposome-containing formulations.

It should be understood that in addition to the ingredients particularlymentioned above, the formulations may also include other agentsconventional in the art having regard to the type of formulation inquestion, for example those suitable for oral administration may includeflavoring agents.

Pharmaceutical formulations adapted for rectal administration may bepresented as suppositories or enemas.

Pharmaceutical formulations adapted for vaginal administration may bepresented as pessaries, tampons, creams, gels, pastes, foams or sprayformulations.

According to certain embodiments, pharmaceutical compositions comprisingCannabidiol, or any derivative thereof according to the presentinvention are also useful for parenteral administration, i.e.,subcutaneously (s.c.), intramuscularly (i.m.), and intravenously (i.v.).The compositions for parenteral administration commonly comprise asolution of Cannabidiol dissolved in an acceptable carrier.

In one embodiment, the compositions of the invention are particularlysuitable for oral administration. The Cannabidiol compositions can beadministered from one or more times per day to one or more times, perweek, including once every other day. Dosing is dependent on theseverity of the symptoms and on the responsiveness of the subject to thetreatment. The skilled artisan will appreciate that certain factors mayinfluence the dosage and timing required to effectively treat a subject,including but not limited to the severity of the disease, previoustreatments, the general health and/or age of the subject, and otherdiseases present.

The present invention relates to the treatment of subjects, or patients,in need thereof. By “patient” or “subject in need” it is meant anymammal for which administration of the composition of the invention isdesired, in order to prevent, overcome or slow down a medical condition.

The terms “treatment”, “prevention” and “prophylaxis” refer to thecomplete range of therapeutically positive effects of administrating toa subject including inhibition, reduction of, alleviation of, and relieffrom, GVHD, specifically, acute and chronic GVHD. More specifically,treatment or prevention includes the prevention or postponement ofdevelopment of the disease, prevention or postponement of development ofsymptoms and/or a reduction in the severity of such symptoms that willor are expected to develop. These further include ameliorating existingsymptoms, preventing additional symptoms and ameliorating or preventingthe underlying causes of symptoms.

It should be noted that particularly in case of human subjects,administration of the compositions of the invention to the patientincludes both self-administration and administration to the patient byanother person.

To provide a “preventive treatment” or “prophylactic treatment” isacting in a protective manner, to defend against or prevent something,especially a condition or disease.

As used herein, “disease”, “disorder”, “condition” and the like, as theyrelate to a subject's health, are used interchangeably and have meaningsascribed to each and all of such terms.

The term “pharmaceutical composition” refers to an active compound inany form suitable for effective administration to a subject, e.g., amixture of the compound and at least one pharmaceutically acceptablecarrier.

The term “therapeutically effective amount” is intended to mean thatamount of a drug or pharmaceutical agent that will elicit the biologicalor medical response of a tissue or human that is being sought by aresearcher, medical doctor, or other clinician, or by the subjecthimself.

As used herein, a “pharmaceutically acceptable carrier” means a carrieror diluent that does not cause significant irritation to a subject anddoes not abrogate the biological. activity and properties of theadministered compound.

A “pharmaceutically acceptable excipient” means an inert substance addedto a pharmaceutical composition to further facilitate administration ofthe compound. Examples, without limitation, of excipients includecalcium carbonate, calcium phosphate, various sugars and types ofstarch, cellulose derivatives, gelatin, vegetable oils and polyethyleneglycols.

The following examples, which further describe the invention, areoffered by way of illustration and are not intended to limit theinvention in any manner.

EXAMPLES Example 1 Prevention of Acute and Chronic GVHD in AllogeneicStem Cell Transplanted Patients

Forty six (46) patients over 18 years of age undergoing allogeneichematopoietic stem cell transplantation at the Rabin Medical. Center inIsrael were recruited. Patients having history of psychosis or asthma,or consuming Cannabis during the last two months before transplantationwere excluded from the study.

All patients received standard GVHD prophylaxis consisting ofcyclosporine twice a day starting on day −1 with target, trough levels≥200 ng/mL in combination with short course of methotrexate (15 mg/sqmon day +1 and 10 mg/sqm on days +3 and +6). Most patients transplantedfrom unrelated donors received anti-T-cell globulin (ATG Fresenius) at alow dose of 5 mg/kg on days −3 to −1.

The investigational agent, CBD (STI Pharmaceuticals, Brentwood Essex,UK) was dissolved in olive oil at a concentration of 2.5% and was orallyadministered from day −7 through day +30. The starting dose of CBD was10 mg twice a day, and doses were doubled every other day to a maximaldose of 150 mg twice a day.

To estimate the prophylactic and therapeutic effect of Cannabidiol, thepatients were carefully monitored and documented for the presentation ofacute and chronic GVHD symptoms, the time of onset, the severity of thesymptoms, the responsiveness to treatment, and the occurrence ofinfections.

Furthermore, we sequentially monitored a panel of 4 serum cytokines(soluble TNF receptor 1 (sTNFRI), soluble IL-2 receptor alpha(sIL2R-alpha), hepatocyte growth factor (HGF), and IL8)). Blood sampleswere taken at days −7(A), 0(B), +14(C), and +28(D). We assessed thedifference in blood levels between the various time points (B-A, C-B andD-C).

Primary end points were safety and cumulative incidence of grade 2-4 andgrade 3-4 GVHD by day +100. The secondary end points were cumulativeincidence of chronic and severe chronic GVHD, non-relapse mortality(NRM), relapse incidence (RD, and overall survival (OS). NRM mortalitywas defined as death while the patient was in CR. Cumulative incidencecurves were used for acute GVHD and chronic GVHD estimation, taking intoaccount. relapse and death as competing risks. Cumulative incidencecurves were used for RI and NRM taking into account disease recurrenceand death as competing events. Probabilities of OS and LFS werecalculated using the Kaplan-Meier estimates.

Median age was 56 (range, 22 to 73) years. Most patients (n=38, 79%) hadacute leukemia and 13 patients (27%) had chemo-refractory disease attransplantation. Twenty patients (42%) received allografts fromunrelated donors. Thirty five patients (73%) received myeloablativeconditioning. Median follow-up of survivors was 10 (range, 1.3 to 18)months. Drug compliance was good, with 32 patients (70%) taking 100% ofthe doses. Non compliance with study medication was mainly due tomucositis and nausea. Median dose dense among non-compliant patients was86% (range, 43%-96%). No grade 3 to 4 toxicities related to CBD wereobserved.

Six patients developed. grade 2 to 4 acute GVHD. Two patients had agut-only involvement, 3 patients had involvement of skin and gut, and 1patient had involvement of gut and liver. Median time to onset of grade2 to 4 acute GVHD was 60 days (range, 41 to 150 days). Cumulativeincidence rates of grade 2 to 4 acute GVHD at day 100 was 12.4%.Cumulative incidence rates of grade 3 to 4 acute GVHD at day 100 was 5%.

Among patients surviving more than 100 days after HCT (n=33), chronicGVHD occurred in 11 patients (overlap, n=3 and classic, n=8), with amedian time to onset of 159 (range, 125 to 335) days. Of the 11patients, 8 had limited Chronic GVHD with a low stage involvement of theoral mucosa and. a mild elevation of liver enzymes. In the 3 patientswith severe chronic. GVHD, organ involvement included eyes (n=3), mouth(n=3), skin (n=3), lungs (n=2) and musculoskeletal (n=1). Cumulativeincidence rates of overall and extensive chronic GVHD at 1 year were 43%and 19%, respectively.

Cumulative incidences of relapse at 100 days, 6 months and 12 monthsafter HCT were 12%, 22%, and 31%, respectively. Non-relapse mortality at100 days, 6 months and 12 months after HCT were 8.1%, 11.6%, and 11.6%,respectively. Overall survival rates at 100 days, 6 months and 12 monthsafter HCT were 84%, 76% and 70%, respectively.

Interestingly, patients with increased D-C serum levels of IL8 andsIL2R:-alpha had a relative risk of 3.8 (95% CI 0.8-17.1, p=0.1) and 2.8(95% CI 1.1-7.5, p=0.05), respectively, for developing chronic GVHD.

The results obtained clearly indicate that administration of Cannabidiolreduces the incidence and severity of acute and chronic GVHD afterallogeneic stem cell transplantation. The findings presented. hereindemonstrate the advantages concurrent with low toxicity and lack ofpsychotropic effects of Cannabidiol in preventing acute and chronicGVHD.

Example 2

Twelve patients over 18 years of age with extensive chronic GVHD afterallogeneic HCT were recruited at the Rabin Medical Center in Israel.Patients having a history of psychosis or asthma, or consuming Cannabisduring the last two months before transplantation were excluded from thestudy.

Patients were presently treated with a calcineurine inhibitor(cyclosporine or tacrolimus) with or without oral prednisone.

Patients, were given oral CBD 50 mg twice a day.

A clinical improvement was documented in 6 out of 8 patients with skininvolvement, 2 out of 3 with lung involvement, 3 out 4 with liverinvolvement and 3 out of 3 with oral involvement.

The results obtained dearly indicate that administration of CBD reducesthe severity of chronic GVHD.

1. A method for preventing a graft-versus-host disease (GVHD) in apatient in need thereof, comprising the step of administering to saidpatient, a composition comprising cannabidiol in a dose of about 5 mg toabout 600 mg, thereby preventing a GVHD.
 2. The method according toclaim 1 wherein said GVHD is acute GVHD.
 3. The method according toclaim 1 wherein said GVHD is chronic GVHD.
 4. The method according toclaim 1, wherein said patient underwent or destined to undergo anallogeneic hematopoietic stem cell transplantation.
 5. The methodaccording to claim 1, wherein said administering comprises administering14 days prior to transplantation.
 6. The method according to claim 1,wherein said administering comprises administering 1 to 30 days aftertransplantation or 7 days to 180 after transplantation.
 7. The methodaccording to claim 1, wherein said composition lacks a psychotropiceffect.
 8. The method according to claim 1, further comprisingadministering at least one additional therapeutic agent.
 9. The methodaccording to claim 1, further comprising administering cyclosporine. 10.The method according to claim 1, further comprising administering:tacrolimus, methotrexate, mycophenolate mofetil, sirolimus, ATG,imatinib a TKI, azathioprine, pentostatin, thalidomide, retinoids,anti-CD20 molecule, anti-CD52 molecule, ECP, a corticosteroid, amesenchymal stem cell, or any combination thereof.
 11. The methodaccording to claim 4, wherein said allogeneic hematopoietic stem cell isderived from the patient's sibling or from an unrelated-donor.
 12. Themethod according to claim 4, wherein said allogeneic hematopoietic stemcell comprises: bone marrow or peripheral-blood stem celltransplantation, cord blood transplantation, haploidentical bone marrow,peripheral-blood stem cell transplantation, or any combination thereof.